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1 Making Lemonade from a Lemon of an NDNQI RN Survey: Nurse Managers and Clinical Nurses Collaborating to Improve the Practice Environment Session ID#: L8 Kathie Krause MSN, RN, NNP-BC, NEA-BC Vice President Patient Care/Chief Nursing Officer Paula Dycus DNP, RN, CPHQ, NEA-BC Administrative Director of Professional Practice and Research

2 Disclosure Today s presenters do not have any relevant financial interests presenting a conflict of interest to disclose. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ache) for this program toward advancement, or recertification in the American College of Healthcare Executives.

3 Session Objectives The participant will be able to: Describe the methods used to enhance communication between managers and clinical nurses and foster leadership skills among clinical nurses Describe the methods employed by clinical nurses to engage and lead staff in creating change in their practice environment Explain how staff driven change contributes to the creation of an empowered unit and professional culture

4 Le Bonheur Children s Hospital Located in the heart of the Memphis Medical Center Academic Regional Referral Center Part of the Methodist Le Bonheur Healthcare System STATISTICS Beds Pediatric specialties - 40 Employees - 2,303 Nurses -914 Medical staff members ED visits - 80,000 /year Level I Pediatric Trauma Center US News and World Report Ranked in 5 Categories

5 Background Journey to nursing excellence began approximately 6 years ago Created an infrastructure based on Magnet framework Developed and implemented shared decision making model Focused on organizational culture shaping Emphasized the principles of Patient and Family Centered Care December 2010 moved to new hospital Change in environment and practice expectations Staff response to change

6 Measuring RN Satisfaction Historical use of annual employee satisfaction survey Utilized internal and external benchmarking Tool served as the only barometer for nursing engagement and satisfaction with their practice and with the organization Results reflected perceptions of individual practice, leadership, and organization Results did not specifically speak to the practice of nursing and the practice environment Professional Nursing Practice Council asked for change

7 Assessing the Practice Environment Professional Nursing Practice Council members aware of the Nursing Work Index-Revised Council asked leadership for assistance in identifying a reliable and valid tool to assess the practice environment Participate in NDNQI for other indicators Introduced the council to the NDNQI tools Council selected the Practice Environment Scale with Job Satisfaction Scale Requested CNO support

8 Survey Implementation Introduced survey and encouraged participation without formal staff preparation Professional Practice Council and Magnet Champions led a grass roots effort Roll out during Nurses Week 2012 Offered nominal incentives for strong unit participation Goal: Exceed the national participation average (75%) Low historical employee satisfaction survey participation by nurses fueled our efforts

9 And the Survey Said

10

11 Uh Oh. The brutal facts-disappointed but not surprised We knew there was work to be done to improve the practice environment for our nurses To be successful, we knew we needed a shared goal, connection among nurses, engagement, and focus Wanted to foster collaboration among all members of our nursing division

12 A Call to Action to Improve the Practice Environment A highly effective practice environment requires collaborative relationships among managers and clinical staff

13 AONE Principles for Collaborative Relationships Between Clinical Nurses and Nurse Managers

14 Effective Communication Engage in active listening Know both the intent and the expectations of the message Foster an open, safe environment for dialogue Communicate accurate information Ensure that the right people receive the information

15 Authentic Relationships Be true to yourself-walk the talk Empower others to have ideas and participate in projects that leverage or enact those ideas Recognize and leverage strengths Be honest with yourself and with others Respect each other Ask for what you want and be willing to negotiate Assume positive intent

16 Learning Environment & Culture Inspire innovative and creative thinking Commit to a cycle of evaluating, improving, and celebrating Create a culture of safety Share knowledge and learn from mistakes Question the status quo

17 Implementing the Principles and Developing Action Plans

18 First Steps CNO held Town Hall meetings with all nurses Communicated a clear accurate message of the results Acknowledged the disappointment Acknowledged that the voice of the nurse had been heard Committed to change Nurse Managers held meetings with unit staff to share unitspecific results Engaged in open & honest dialogue Clinical nurses were encouraged to share their perceptions of survey results Managers and staff agreed that everyone wanted a healthy practice environment---a shared goal Staff were challenged to engage in the development of potential solutions to identified issues

19 Next Steps Engaged ANCC Magnet Consultant to facilitate a workshop to develop unit-specific action plans Participation by Unit Council Chairs, Magnet Champions, and Nurse Managers with leadership support Emphasis placed on understanding results and action planning on issues most critical to unit nursing staff Developed 2 plans/unit with timelines for completion and reporting-focus and commitment Built consensus with unit staff before implementation to ensure engagement and thorough communication

20 Workshop Strategies Everyone checks their badge at the door Be respectful of other people s ideas Be creative and think outside the box Encourage and empower every attendee to express ideas and concerns Consider the workshop a learning event we are here to learn from each other and gain insight Commit to a cycle of evaluating, improving and celebrating

21 Action Plan Execution Implementation over next 9 months Data collected pre- and post-implementation to measure true outcomes Plans and outcomes reported to unit staff and nursing leadership per established timeline Goal was to have all projects complete by next survey cycle Will share three staff and one organizational project

22 Le Bonheur Projects Staff driven projects Eliminating lateral violence ICU turn team Resource nurse Organizational Project Staffing analysis

23 Eliminating Lateral Violence: Don t Blow Out My Candle Staff identified that lateral violence contributed to dissatisfaction with staffing and resource adequacy Reduction of lateral violence improves teamwork and creates a healthier work environment The burning candle represented a pleasant and supportive environment

24 Eliminating Lateral Violence: Don t Blow Out My Candle Surveyed staff using Bully Behavior Assessment Tool to assess staff s knowledge of lateral violence and the extent of its presence on their unit over the project period Conducted group training sessions using role playing and teach back strategies Committed to zero tolerance for lateral violence behaviors

25 80 70 Presurvey 3 Months April 70.8% % % % % 19.2% 16.7% % 4.2% 0 Weekly A Few Times Never

26 Pre Survey 3 Months April % % 41.4% 33.3% 40.7% % % % 3.8% 0 Weekly A Few Times Never

27 Presurvey 3 Months April % % % 48.3% % 6.9% 8% 3.7% 0% Weekly A Few Times Never

28 ICU Turn Team Staffing and resource adequacy was lowest domain Change in physical ICU configuration contributed to increased feelings of staff isolation and lack of assistance for patient care Turning q2h was identified as being inconsistent among staff, especially when time or assistance was not available Conducted time motion studies to assess time to turn all patients (12-20 minutes) Surveyed staff about their perceptions of success using this program Developed 2 person team to turn all patients during their assigned time period

29 ICU Turn Team Only 38% of staff participated in the initial survey Other patient care responsibilities kept staff from fulfilling their commitment to the turn team Patient s nurse not always supportive of having other staff involved in patient care Only 50% of staff felt that turn team was the answer to assisting with this patient care need

30 Resource Nurse--IMCU Staffing and Resource adequacy was lowest scoring domain Perceptions related to: novice staff increasing patient acuity high number of patients going off unit for procedures new physical unit configuration complex discharges Surveyed staff using questions similar to NDNQI Over 50% of staff participated Altered methods for assignment making to allow charge to not carry patient assignment Allowed charge nurse to be available for transports off unit, assistance with admissions/discharges, and clinical resource to new staff

31 During the last shift, I had enough: p =.002 p = = strongly disagree, 5 = strongly agree

32 Staffing Analysis Staffing and resource adequacy was lowest score on National Database of Nursing Quality Indicators (NDNQI), as well as, employee satisfaction survey Investigated benchmarking opportunities Used NDNQI, Labor Management Institute (LMI), and Children s Hospital Association (CHA) for direct and total hours per patient day (HPPD) across all nursing units Goal was to be in the 50 th percentile Direct HHPD and skill mix changes made in 100% of med/surg units and 66% of step-down units

33 Other Contributing Factors Revised floating guidelines Capital equipment purchases Leadership changes Residency program changes Focus on quality at the bedside

34 Preparing for Survey 2013 Repeated in August, 2013 to allow project completion and have larger benchmark data set Eliminated several cost centers (groups) due to lack of available benchmark data Increased survey promotion efforts but continued to let staff lead the way Multiple staff meetings held to highlight accomplishments over last year at the nursing division and nursing unit level Repeated incentives for strong participation and created competition among units Celebrated by showcasing project results during the Innovations in Nursing Expo

35

36 And the Survey Said

37 Overall 2012, 2013, and National Benchmark Comparison Scores Mean Practice Environment Score Participation in Hospital Affairs Quality of Care Manager/ Leadership Staffing and Resources Nurse- Physician Relations

38 Now What Town Hall held by CNO to celebrate and share overall results with staff Professional Practice Council, Magnet Champions, and Nurse Managers shared unit level results Action planning workshops and new project creation began in January, 2014

39 Creating a Learning Environment Questioning the status quo has big payoffs changing the survey was the catalyst for success and improvement in the practice environment Projects were innovative and originated from our clinical nurses Better results are achieved when staff are supported to lead the effort even when that effort is not successful Our clinical nurses developed a stronger sense of empowerment and confidence after leading these efforts and sharing their results with peers & colleagues

40 Implications for Practice Nurse satisfaction is tied to a healthy work environment There is great value in clinical nurse involvement Validates the value of shared decision making Lets staff know that leadership listens Gives nurses rapid cycle improvement experience Supports risk taking and innovation Helps staff to understand that every idea is not a successful idea and every change isn t an improvement and that is OK Creative and innovative ideas developed at the point of care are most effective in improving the practice environment

41 Questions

42 Speaker Contact Information Kathie Krause: Paula Dycus:

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