A Hospital's Roadmap for Improving Nursing Excellence Using AACN's Healthy Work Environment Standards.

Abstract

The nursing profession is in crisis as we move out of pandemic-related staffing pressures and move into shortages driven by retirement of the Baby Boom generation. Burnout in nursing was significant prior to the pandemic.1 According to Buerhaus,2 factors driving the current staff shortage include the retirement of one-third of the nursing workforce between 2010 and 2030, an increase in demand for nurses as the result of the expansion in both inpatient and outpatient specialties, and a growing number of frontline nurses who want to move into advanced practice positions. Per Buerhaus,2 an estimated 640 000 nurses will retire between 2020 and 2030, although some may have left early over the past 2 years because of the pandemic.Traditional recruitment and retention strategies such as sign-on bonuses and other financial incentives are temporary solutions for the larger problem. Sign-on bonuses, for example, were given during the last major nursing shortage in the early 2000s; they did not remedy the larger trend. Sign-on bonuses are an insufficient measure for resolving large shortages, and they can be demoralizing for current staff who have chosen to stay.3 According to Burke and Ropp,3 “the sign-on bonus is an expensive, short-lived tactic to fill slots.”This column will focus on one hospital’s attempt to implement long-term plans focused on the American Association of Critical-Care Nurses (AACN) Healthy Work Environment Standards: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.4 Per Munro and Hope in an American Journal of Critical Care editorial before the pandemic, the standards “support improved outcomes for both patients and nurses and for the health care team.”5According to AACN, for skilled communication to occur, “Nurses must be as proficient in communication skills as they are in clinical skills.”4 Blake et al6 found that the better the communication and collaboration, the better the patient outcomes. Collaboration and communication are increasingly essential in hospitals, and as such, hospitals are developing programs to encourage teamwork. TeamSTEPPS is a good example of a program that can be implemented to train staff in formal communication processes.7 The Joint Commission has set a leadership standard to ensure abusive behavior is dealt with by management; they have also developed hand-off communication recommendations because a large percentage of sentinel events had inadequate communication as a root cause.8 One method to improve collaboration is a triad leadership team for each unit: a nurse leader, a physician leader, and an administrative leader. This triad model with joint accountability brings the team closer together in order to address issues.Decision-making is improving in many health care systems with the implementation of shared governance. The primary purpose of the Shared Governance Council (SGC) at Los Angeles County University of Southern California (LAC+USC) Medical Center is to implement and continuously improve the unit- and department-specific Relationship©Based Care (RBC) delivery model and related outcomes. The SGC enculturates a shared governance decision-making model within the organization, which allows clinical staff to express and manage their practice and offers a high level of professional autonomy and accountability for the nursing staff. The SGC assumes accountability for the operation and integration of shared governance. A dynamic partnership between those who provide service or support within a health care system will promote excellence, collaboration, timely communication, shared decision-making, accountability, and ownership. This partnership is accomplished by using the account-abilities for shared decision-making to guide the work of the nursing staff. Responsibilities of the SCG include practice or service issues, the practice or work environment, performance improvement, and professional development. Shared governance enables sustainable, accountability-based decisions to support an interprofessional design for excellent patient care.9 Shared governance assures that decisions are aligned with the organizational mission, vision, values, and strategic goals and fully empowers professional practice scope.Bedside nurses in health care today are challenged with more complex patients and increased health care demands.10 California’s nurse-to-patient ratios (as established by California Assembly Bill 394) define the maximum number of patients to whom a nurse can be assigned. Furthermore, the law requires a patient classification system that calculates the amount of nursing care a patient will need for a specific shift. The law was developed to improve staffing and patient outcomes, as research has indicated that higher staffing levels improve patient outcomes.11A staffing, scheduling, and patient acuity system is an example of an evidence-based system that provides tools to assign staff on the basis of patient acuity as determined by nursing outcomes classification and standard outcome sets that minimally adhere to nurse-to-patient ratios. Advanced technology calculates staffing by patient acuity and hours of care to determine individual patient care needs. The system automatically extracts predetermined patient care data points from clinical documentation. Our system standardizes acuity levels and hours of care needed for each patient. Furthermore, it removes subjective assessments and allows for equity of assignments among nursing staff. This acuity tool helps eliminate the need to make patient care assignments on the basis of patient location and personal bias or staffing ratios alone. Data are collected from the clinical documentation with alignment of previous admission, discharge and transfers, and adjusted hours per patient day. Patient acuity levels are also based on budget data, which helps facilitate staffing assignments. A 75% documentation threshold is required to generate patient acuity. The frontline trained nursing staff complete peer review audits and interrater reliability monitoring to validate the tool monthly. Thus, nursing staff learn to trust the system and ensure the system pulls the appropriate patient care data points to compute patient acuity. The goal is to provide tools and data to determine when there is a need for additional nursing staff higher than the mandated patient-nurse ratios, make equitable assignments, and promote optimal decision-making in real time.While scheduling shifts for nurses is an important part of daily staffing, having strategies to recruit, decrease turnover, and meet staffing needs of patients is also important for retention. Self-scheduling is one strategy that offers flexibility to both the employee and the hospital by allowing nurses to work shifts that meet their personal needs and accommodate a work-life balance. A great recruiting tool, self-scheduling provides a sense of autonomy in the work environment and creates a sense of professionalism. The interactive process in self-scheduling provides transparency, as nurses can see coworker preferences and department needs, and can improve communication and increase team building. Self-scheduling reduces conflicts and enables nurses to trade shifts with peers. Employees feel more in control of their lives, which improves staff satisfaction. Self-scheduling also lets the manager spends less time preparing schedules and can be used as a strategy to decrease absenteeism and improve staff retention and satisfaction.The staffing, scheduling, and patient acuity application system supports self-scheduling and is web-based, allowing staff to see their current daily schedule. The system provides real-time data and has features to improve communication between coworkers and managers. For example, when a nurse wants to change shifts, it provides a view of their current schedule, all staff available whose schedules could accommodate the trade, and a view of what those changes would reflect to the nurse’s schedule. One text is sent to all potential staff who could trade, and managers can evaluate those trades and approve with electronic data to track all changes, approvals, and communication. In addition, the system can be used to alert staff within 24 hours of increased staffing needs due to absenteeism or increased patient acuity. One mass communication is sent to all nurses who are available, who can then respond with tracked electronic communication.Safe staffing is essential to maximizing patient outcomes and staff satisfaction, and self-scheduling is a great tool to reach that goal.When considering the daily challenges of running a hospital, combined with the impact of COVID-19 on nursing staff, it is easy to lose sight of what is important: recognizing nurses and their accomplishments, whether big or small. Now more than ever, having a meaningful recognition program is vital to nurses feeling valued and appreciated. A healthy working environment that supports nurse retention recognizes individual or team successes in a genuine, consistent, and meaningful way. As a proud DAISY partner, LAC+USC Medical Center continues to celebrate and recognize an extraordinary front-line nurse every month for the compassionate way they deliver care. In 2021, we expanded our DAISY recognition program to include the DAISY Nurse Leader Award in time for Boss’ Day. The dedication, hard work, innovative ideas, and adaptability our nurse managers demonstrated amid the pandemic was truly remarkable, and we needed to ensure they are acknowledged and recognized.Each member of the health care team is important, thus we have the Shining Star award to honor ancillary staff: clerks, nursing assistants, and technicians who go above and beyond and shine the brightest for the benefit of others. Awardees exhibit the qualities of a STAR: supportive and sincere, trustworthy and a team player, adaptable and a patient advocate, and respectful and responsible. Elevating and embedding relevant, strong, and meaningful recognition practices inspires employees to contribute to a healthy and professional work environment.Authentic leadership is an important to tool in promoting nurse retention. Blake et al6 found that nursing leadership was the most important factor related to nurses’ intent to leave their job in the next 6 months in the pediatric intensive care unit (P < .01).6 Old-school top-down management styles are no longer effective. Nurse managers need to understand their role as chief retention officers and servant leaders. In order to do that, there needs to be a professional development program for nurse managers. Many nurse managers are promoted on the basis of their clinical skills and nursing expertise in their unit. When we fail to provide professional development for nurse managers, they may fail in their new roles, which in turn results in high turnover. The organization should provide ongoing education and mentoring of managers tailored to support nurse manager competencies. Saifman and Sherman12 noted that leadership development, coaching, and mentoring are needed for ongoing competency development, quoting leadership expert John Maxwell: “our own ability as leaders will ultimately be measured by how well those who follow us are prepared to lead in our absence.”New graduate residency programs have been in place for more than 20 years. Data have shown a significant decrease in turnover in the first 2 years, relative to what turnover looked like before these programs. The Practice Transition Accreditation Program for Registered Nurse Residency is a structured, comprehensive program for registered nurses with less than 12 months of experience. The programs support skills acquisition for new graduates and include organizational orientation, practice-based experience, and supplemental activities to promote nursing professional development.13 Structured, accredited nurse residency programs lasting 6 to 12 months have been shown to improve new graduate retention, competence, and the confidence required to practice autonomously and in collaboration with other disciplines.14 The data showing the benefit of new graduate transition to practice programs underscore that these programs are essential for onboarding new graduates; they can aid in retention of new graduates and be a cornerstone of a successful retention program. Trepanier and colleagues15 found that the 12-month turnover across 15 primarily community-based hospitals decreased from a mean of 36.8% preresidency to a mean of 6.41% postresidency. New graduate programs build confidence and competence, which ensures a rewarding transition to practice.16AACN’s Healthy Work Environment Standards are a blueprint to implement a healthy work environment. This was one facility’s roadmap to support a healthy work environment. It is a journey, and our work is not done, as we have to hire staff to fill open positions and closely collaborate with the frontline staff to meet their needs and support retention.