Staff engagement recently has emerged as an important topic of interest, particularly as it relates to employee performance and organizational management. Engagement is defined as a worker's commitment to the organization where workers are happily involved in work, are energized, have an experience of belonging, and take pride in work relationships (Garrosa, Moreno-Jimenez, Rodriguez-Munoz, & Rodrigues-Carvajal, 2010). A body of growing evidence suggests a direct correlation between staff engagement and improved outcomes for the organization as measured by quality indicators, patient satisfaction, staff turnover, and staff productivity (Bargagliotti, 2012; Press Ganey Associates, 2013).
In addition to treating more patients with a high acuity, hospitals are faced with the rapid implementation of advanced technologies, an increase in workplace violence, and budget constraints. Collectively and individually, these factors are associated with job-related stress. These job-related stressors, combined with the emotional burden of the job (i.e., nurses appear proficient but the work is taxing both physically and mentally), are such that nurses often believe they are not valued, which leads to a disengaged culture of teamwork among nursing staff and a lack of motivation within the work environment (Bargagliotti, 2012). The lack of an engaged workforce and ineffective teams can result in a higher rate of medical errors, ineffective communication skills, the inability to resolve conflicts, and the ineptitude to support colleagues in critical situations (Clancy & Tornberg, 2007; Kalisch, Weaver, & Salas, 2009). With an increased emphasis on patient safety, health care organizations are looking at the importance of engagement and teamwork to improve safety (Bargagliotti, 2012; Garrosa et al., 2010).
What Is Already Known
Press Ganey Associates Inc. (2013), a company that measures patient experience and performance analytics, acts as an advisor for health care organizations. In reviewing engagement among health care providers, the company has found that for every 100 nurses, 15 nurses are considered disengaged, meaning that these nurses lack commitment or are dissatisfied with their work. When analyzing costs, a disengaged nurse costs an organization $22,200 in lost revenue due to lack of productivity (Schaufenbuel, 2013). When multiplied across a large health system that hires between 10,000 and 15,000 nurses annually, an organization could be looking at a potential loss of up to $50 million yearly (Dempsey & Reilly, 2016).
In addition, nurse disengagement is linked to lower rates of nurse retention, another important national issue (Simpson, 2009). On average, the national turnover rate for nurses is 16.4%, with the average cost of turnover per nurse ranging from $36,000 to $57,000 (Dempsey & Reilly, 2016). Press Ganey's (2013) staff engagement data further suggest that nurses who are not in direct patient care roles are more engaged than their colleagues who provide direct patient care. This is disheartening, as front-line staff play a key role in patient satisfaction and quality, which is a constant focus for hospitals throughout the United States. It is vital for the nursing profession to examine staff engagement and develop systems to ensure that nurses are both engaged and empowered to make changes in their work environment.
Several studies have demonstrated that when nurses are engaged in their work, teamwork improves. Effective teamwork is linked to increased job satisfaction, improved quality of care, and increased patient satisfaction (Cummings, 2013; Garrosa et al., 2010). The importance of teamwork also has been highlighted in reports by the Joint Commission on Accreditation of Healthcare Organizations (2005) and the Institute of Medicine (2012), which both state that interdisciplinary teams function as a major asset to ensure patient safety.
It is imperative to examine staff engagement and then use what is learned to develop and implement systems to ensure staff feel engaged and empowered to make changes in their work environment. One concept based on evidence-based practice is to align nursing staff by creating an interprofessional care team with the implementation of a professional practice model, which has a set of unique nursing values to drive standardized practice. When nursing shares a common vision and values from a framework of a professional practice model, there is increased satisfaction for nurses within the work environment, improvement in nurse communication, greater retention of nurses, improvement in quality outcomes, and a decrease in costs (Turkel, 2004).
Using a Focused PICOT Question to Drive the Project
Staff nurses working under an established professional practice model can better promote the discipline of nursing. A model helps standardize nursing practice, provides guidance, and elevates nurses to function beyond tasks in a theory-driven practice. This engagement sets the stage for true patient-centric care (Glassman, 2016). These core values help strategize the vision of an organization. Evidence has indicated that a model can provide a guide to increase health care professionals' engagement (Afsar-Manesh, Lonowski, & Namawar, 2017).
A PICOT question (Population of concern, Intervention or issue, Comparison, Outcome, and Time frame) was used to determine whether staff nurses at a tertiary medical center (P) by implementing a professional practice model with lean management principles (I) compared with current standard practices (C) could make an impact on staff engagement and staff empowerment, and develop a sense of a nurse community (O) within 6 months of an intervention (T). The end goal was to lead ongoing change to facilitate engagement and empowerment in frontline staff while aspiring to create a deep culture change within the organization.
Sources and Literature Search Process
The PICOT question guided a systematic search using the following key words: nurse, nurse engagement, staff engagement, empowerment, patient satisfaction, improvement, professional practice, practice model, relationship-based care, and quality improvement. The databases used were Cochrane, CINAHL®, PubMed®, and Evidence-Based Journal; in addition, textbooks were queried. The initial search yielded more than 5,750 articles. Key words were truncated, duplicate articles were eliminated, and a concentration of evidence related to answering the PICOT question identified approximately 250 articles.
Articles for inclusion addressed nurse empowerment and engagement with a professional practice model. An article was excluded if it addressed only performance improvement or retention, concentrated on professions other than nursing, or did not focus on engagement or empowerment. After applying the inclusion and exclusion criteria, a total of 53 articles were identified; of these, five articles that best addressed the PICOT question were selected. Studies in this review were critically appraised by the Johns Hopkins Research Evidence Appraisal Tool or the Non-Research Evidence Appraisal Tool (Dearholt & Dang, 2012).
The conceptual framework that helped guide this project with the aim to improve nurse engagement had three components:
- A professional practice model that fit the desired work and goals of the target organization.
- Koloroutis' (2004) relationship-based care model to help staff nurses connect to patients and find purpose in their work.
- Felgen's (2007) change theory to help enculturate the work.
Professional Practice Model. This project implemented an existing nursing professional practice model comprising six core nursing values: professionalism, patient-centric care, empathy, teamwork, compassion, and integrity. These core values help form the vision of the organization. The model itself usually is depicted in a representational model and outlines values, such as patient and family centric, teamwork, integrity, and professionalism. Working under a professional practice model with the opportunity to work in this environment enhances staff engagement, ultimately leading to strong quality and patient safety indicators (Albanese, Aaby, & Platchek 2014).
Relationship-Based Care Model. Koloroutis' (2004) relationship-based care model was the nursing framework used in this project for the implementation of the professional practice model. The model has adopted Koloroutis' three key relationships that influence culture: relationship with self, relationships with team members, and relationships with patients and families. These relationships are interdependent, and the ultimate relationship with patients and families is dependent on the nurse's healthy relationship with self as well as with the nurse's work team. Recent research by Koloroutis and Abelson (2017) further explains that when individuals are stressed and stretched beyond their means, the culture of the organization also is stretched and stressed. However, if individuals find diverse ways to take care of themselves while caring for others, this promotes an organization that creates a caring culture.
Change Theory. To help enculturate the work environment, Felgen's (2007) change theory was used. This theory comprises four essential elements: inspiration, infrastructure, education, and evaluation, referred to as I2E2. The theory helps to inspire culture change within an organization and engage key stakeholders to establish a structure to lead the work. This formula has been shown to help with designing, implementing, and sustaining cultural change (Felgen, 2007).
Inspiration allows nurses to see the benefits of the change and how it outweighs the risk of upsetting the current system's status quo. Infrastructure allows for the ability to bring about the change successfully and to create a new vision with systems and practices that already exist. It also helps to establish a strategic plan and enables staff to focus on a central vision for change. The education element of the formula helps to assess the staff's current knowledge and enables the organization to determine what educational offering needs to exist to advance the vision for change (Felgen, 2007). Education helps staff gain the ability to engage in the change. The evaluation component of the formula assesses how successful inspiration, infrastructure, and education are implemented in setting the organization's new vision for change.
The specific aim of the project was to implement a professional practice model to improve nurse engagement and teamwork, as evidenced by:
- Increased nurse knowledge regarding a professional practice model by 10% from baseline.
- Improved staff engagement as measured by People Pulse (the organization's employee engagement survey) engagement index by 2% from baseline.
- Improved culture of teamwork as measured on the Cultural Questionnaire (Zammuto & Krakower, 1991) by 10% from baseline.
- Decreased nurse-sensitive quality metric of patient falls per 1,000 patient days from five to zero by 6 months.
The project was conducted on a 48-bed medical-surgical-telemetry unit at a medium-sized (225 licensed beds) tertiary medical center. The unit provided the ability for all health care providers to receive the same evidence-based interventions. The unit consisted of 100 RNs, 10 patient care technicians (previously known as nursing assistants), one nurse manager, one department secretary, and six assistant nurse managers.
The readiness to embark on the journey of nurse engagement and increase the essence of teamwork on the unit was favorable to both management and senior leadership who were supportive of the intervention. The unit had an established quality committee, known as Creating Lasting Change (CLC). It was established in 2014, after the entire medical center staff attended a conference with Tim Porter-O'Grady and read his work on self-governing councils (Porter-O'Grady, 2003). However, this committee had become stagnant. The committee members acknowledged they needed a refresher to advance the committee with further education and to develop strategic projects that aligned with the goals of the organization. The unit was chosen because of several indicators: (a) staff morale had declined, (b) there was a lack of perceived teamwork among the staff, and (c) the unit had an engaged manager who was willing and ready to implement a change to improve quality outcomes and foster teamwork. A project outline was developed to provide a framework and presented to the team at their team meeting.
The purpose of implementing and enculturating the elements of a professional practice model was to get to the emotional principles and the very soul of nurses at the medical center. This was undertaken to create an environment in which nurses felt engaged and in which a culture of teamwork could be developed.
The unit's CLC committee previously had worked on several improvement initiatives that centered on quality outcomes, safety, and care experience. The staff were aware of performance improvement methodology and was familiar with the elements of small test of change or Plan-Do-Study-Act (PDSA) cycles. Staff also were well-attuned to the knowledge that the team needed to become a more robust council, to create a professional governing council, and to embed the six core values to drive and lead professional practice on the unit.
A work breakdown structure was developed and focused on providing a framework for developing the interventions, implementations, and evaluations of the professional practice model using Felgen's (2007) change theory I2E2 (Figure 1). The major components of the work or functions were subdivided into four main categories: inspiration, infrastructure, evidence, and education. The major concepts helped drive change at all levels (management and staff) in which the intervention took place.
Work breakdown structure. Note. CLC = Creating Lasting Change; NEBP = nursing evidence-based practice committee.
Under “inspiration,” the tasks ranged from understanding the current state, hence the cultural assessment, to visually posting inspirational messages on the nursing unit. Under “infrastructure,” tasks were designed to organize the various roles, practices, standards of practice, and processes. Felgen (2007) used the concept of infrastructure to help advance the realization of the vision for change. Some of the tasks included regional consultants observing and aiding in the implementation of a professional practice model, formulating and organizing an existing committee to become a nursing evidence-based practice committee, and concentrating on evidence-based practices to further align the infrastructure.
Under “education,” nursing workshops included “See Me as a Person,” which was based on the theoretical framework of Koloroutis (2004). The relationship-based care theory was taught to all RNs on the unit and to employees of the organization by facilitators trained in the content. Nursing staff were exposed further to the six components of the professional practice model in a nursing fair hosted by the CLC team, which reinforced the elements of the six core values in the form of stations that all staff members were required to attend. During the workshop, staff were introduced to elements of lean principles, such as visual board management, readiness, data collection, and data interpretation; this was provided by the organization's performance improvement director who helped the team use the data to prioritize projects or initiatives for the unit.
Nursing staff on the unit, including nurse leaders, attended a 1-day workshop and were introduced to the concepts of the professional practice model and how to incorporate the six core nursing values into their existing nursing practice. The workshop started with a visioning exercise to help staff reflect on why they entered nursing. The organization's journey of incorporating lean methodology was outlined with the introduction of the “Lean House” (a pictorial that outlined the strategy of the organization) and how the staff's role fit into the organization's strategy. Quality data, such as the unit's patient fall data, patient satisfaction scores, and harm index, was discussed so staff had a basic understanding of their unit metrics. A strengths, weaknesses, opportunities, and threats (SWOT) analysis also was completed.
SWOT. In developing a market analysis, the SWOT analysis was used to identify priorities that aligned with the values and the overall mission of the health care facility and provided clarity for where the unit-based team (CLC) would focus its energy. By completing the SWOT analysis, the unit team laid the framework to prioritize its action plan moving forward.
Unit-Based Team (CLC). The original CLC team, which was composed of volunteers, engaged new membership who wanted to drive change on their unit. The team used the findings from the SWOT analysis to ensure that the unit continued to work on the gaps identified. The CLC team also underwent education in performance improvement, facilitation, understanding, and interpreting data, as well as leadership skills 2 weeks after the initial 1-day workshop.
The goal of this project was to determine whether staff on the unit would gain knowledge in the elements of a professional practice model and how the model's six core values influenced their practice. Although the Cultural Questionnaire included 20 questions that ranged from clinical practice to knowledge of professional practice, only 10 questions were selected to provide an understanding of what a professional practice means and its influence on one's practice. Highlights of the findings were:
- Respondents showed a 10% increase postintervention for the question, “Have you seen or been exposed to a professional practice model and its vision and values?”
- Respondents showed a 33% increase postintervention for the question, “What does a professional practice mean to you?”
- Respondents showed a 5% increase postintervention to the question, “Why is the vision, values, and having a professional practice model important?”
A survey to measure staff engagement showed improvement in all categories from pre- to postintervention (Figure 2). Postintervention, respondents' understanding of how their role impacted goals of the organization increased by 6%, and respondents' understanding of their own goals improved by 15%. The percentage of respondents who indicated they would recommend the organization as a good place to work increased by 13%, and the percentage of respondents who indicated they would prefer to stay with the organization even if a similar job was available elsewhere increased by 11%. The percentage of respondents who believed the organization did a good job providing information on how well staff were able to meet their goals improved by 11%. Finally, the percentage of respondents who noted they were proud to work for the organization increased by 7%.
Engagement survey pre- and postimplementation of the intervention.
Staff also were asked to complete the Zammuto and Krakower (1991) Organization Culture Questionnaire (Figure 3). Each of the questions contained four descriptors of organizations, and staff were asked to evenly distribute 100 points among the four descriptions they felt their current organization was like. The scores then were totaled and divided by 5 to achieve a profile score.
Teamwork culture: Zammuto and Krakower (1991) Organization Cultural Questionnaire. Note. Org. = organization.
Comparing preintervention and postintervention scores, there was a 13% increase in staff who believed their organization was more like Organization A. This was a place that was more personal where managers were warm and caring, the organization was loyal, the organization emphasized high cohesion, and rewards were distributed equally among its members. There was a 5% increase in staff who believed the organization was more like Organization B, which characterized a dynamic and entrepreneurial-ship environment where managers were risk-takers, the organization's cohesion was built on a commitment to innovation, the emphasis was on growth and acquiring new resources, and rewards were based on individual initiatives. There was a 12% decrease in staff who thought the organization was like organization C, which characterized a more structured and more formal environment where managers were rule enforcers, the organization's cohesion was built on formal rules and policies, the emphasis was on permanence and stability, and rewards were based on rank. Finally, there was a 6% decrease in staff who believed their organization was like Organization D. This organization's character was based on production orientation: managers were coordinators and coaches, cohesion was likened to tasks and goals, the emphasis was on competitive actions and achievements, and rewards were based on achievement of the objectives (Figure 3).
Patient falls on the unit were problematic prior to 2017; therefore, a performance improvement initiative to reduce patient fall rates was started in early 2015. This initiative caused a significant shift in the decline of patient fall rates, but there were issues on the unit to sustain the gains. With the reinvigoration of the CLC team, the quality arm of the CLC group undertook ownership of the patient fall issue. From recent data, although there were three patient falls during the intervention time frame, the unit had sustained no patient falls in the 2 months within the intervention time frame.
Expediting the role and influence of nursing during the next 5 years and enhancing interprofessional care teams that embody patient- and family-centric values as standardized practice is the goal for many health care systems in the United States. When nursing within an organization values a professional nursing practice model, it is more likely that nurses will be satisfied with their work environment, enjoy increased communication, improve retention of nurses within the organization, improve quality outcomes, and decrease costs (Turkel, 2004). The aim of this project was to implement a professional practice model to improve nurse engagement and teamwork. Indicators of success were articulated as an increase in knowledge of a practice model by 10%, and the project's intervention helped exceed this target. Staff engagement also increased beyond the 2% cited in the aim.
Key Findings and Lessons Learned
Staff ownership of issues and the ability to resolve them helped motivate staff and develop cohesiveness. Key findings and lessons learned included the following:
- When staff are focused and know the goal and objectives for the reason “why” behind certain initiatives, staff can define the role they play in moving certain metrics forward.
- Other staff who visited or floated onto the unit noted anecdotally that staff on the unit were engaged, that morale was high, and that each person on the unit could articulate the metrics of quality, safety, and care experience data.
- Several nurses on the unit returned to school or started their education path toward national certifications.
- One major lesson learned was the difficulty in explaining the Cultural Questionnaire, which required several meetings with staff before an understanding was achieved.
The successful implementation of the project stemmed from senior leadership support, an engaged manager who wanted change on the unit, and staff who were willing to look at themselves and decided that they could definitely do better to improve patient-centric care and provide effective quality care on their unit.
Nurses who are engaged often feel loyal and dedicated to the organization and help to create an environment that is safe, efficient, and effective (Kalisch, Curley, & Stefanov, 2007). Implementing a professional practice allows for transparency of data and decision making, thus guiding staff to make the right decisions that lead to effective quality and safe patient care. Implementing such a model creates an opportunity for nurses to become influential leaders in our health system.
The purpose of implementing and enculturating the elements of a professional practice model was intended to reach the soul of each nurse at the medical center and create an environment in which nurses are engaged and a culture of teamwork exists. A professional practice model allows for transparency of data, enabling staff to make the right choices in providing effective quality and safe patient care while creating the greatest opportunity for nurses to become influential leaders in our health system.
Staff nurses working under an established professional practice model promote the discipline of nursing. Nursing is the protector, promotor, and optimizer of health; is the preventer of injury and illness; alleviates suffering through appropriate treatment; and is an advocate in the care of patients, families, and communities (American Nurses Association, 2010). One way to change what is not currently working is to drive improvement actively through a professional practice model. Incorporating certain elements of lean principles provides a framework for meaningful quality nursing practice. The concepts on their own have demonstrated how to increase engagement among participating health care professionals, with strong evidence to indicate that a professional practice model can provide a guide. Further research is needed in leveraging both the concept of a professional practice model and lean principles.
Nurses themselves must become the conduit for change, embrace the uncertainties, and become drivers of their own professional practice. Working in an environment that enhances teamwork, with an engaged workforce, will help to reduce errors, improve quality outcomes, and provide a healing atmosphere for true patient-family-centric care.
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