Brandon “Kit” Bredimus was the recipient of AONL’s 2018 Pamela Austin Thompson Early Careerist Award. He helped to develop and implement the program detailed below, which improved nurse engagement and patient experience scores. Brandon “Kit” Bredimus was the recipient of AONL’s 2018 Pamela Austin Thompson Early Careerist Award. He helped to develop and implement the program detailed below, which improved nurse engagement and patient experience scores. Nurse engagement and patient experience scores are 2 essential measures for nurse leaders to understand and support. Nurse leaders can have a direct effect on staff engagement, which can then have a positive or negative impact on patient outcomes.1Boamah S.A. Spence Laschinger H.K. Wong C. Clarke S. Effect of transformational leadership on job satisfaction and patient safety outcomes.Nurs Outlook. 2018; 66: 180-189Google Scholar, 2Oh J. Cho D. Lim D.H. Authentic leadership and work engagement: the mediating effect of practicing core values.Leadersh Organ Dev J. 2018; 39: 276-290Google Scholar An engaged and inspired nursing staff has been shown to create better patient outcomes and higher perceptions of care.3Dempsey C. Reilly B.A. Nurse engagement: what are the contributing factors for success?.Online J Issues Nurs. 2016; 21: 2Google Scholar Although multiple factors constitute nurse engagement, fostering a sense of purpose driven by personal values plays a significant role. Nurse leaders can help drive engagement through the integration of values-based leadership and connection with the mission and vision of the organization. When the new patient tower at Midland Memorial Hospital in Midland, Texas, opened in December 2012, the hospital’s leadership team was confident that the $176 million building, complete with a state-of-the-art emergency department (ED), would boost ED patient experience and nurse engagement scores, both of which had been historically underperforming. With the new architecture came a higher expectation of patient experience by both the community and the staff. Yet staff struggled to meet patient expectations. It was also identified that the ED needed to address employee attitudes toward the patient experience and with the staff’s negative emotional energy. Patient experience scores soon hit the first percentile, and the ED was rapidly gaining a substandard reputation in the community. Staff engagement also hit an all-time low as the focus shifted to the negative trend in scores. Between 2013 and 2014, the ED turned over almost half of its staff. New employees were recruited from the local schools, but this led to a very young crew of new staff with little training on patient communication and the importance of the patient experience. Nurses and providers expressed frustration with their inability to effectively communicate with patients and colleagues. Transparency in scores was also a challenge, because staff and providers were rarely aware of the monthly scores and saw only negative comments when they were approached by leadership for investigation. The staff did not understand what the scores were measuring or the actual values; rather, they were just “bad.” Poor relationships between providers and staff were prevalent in the department and often spilled over into patient care and caused patients to rate their care poorly. It was clear that the ED could not sustain this path. Drastic action needed to be taken to empower and engage staff to help improve the patient experience; staff needed to see the value in improving the patient experience from both an objective and emotional viewpoint. The primary goal for the organization was not to simply raise patient satisfaction scores in the ED, but rather, improve the patient experience from every aspect of the hospital visit. The new initiative needed to start with the staff first, and focus on improving emotional intelligence to begin to create any sustainable change. The organization began to identify the financial cost of emotional negativity in the hospital, and its effect on the patient experience. The hospital engaged with a consultant to develop a hospital plan centering on values and an ownership culture. The organization trained more than 40 staff members to become values coaches and began rolling out classes to all hospital staff focusing on the importance of identifying and living your values. The entire organization was able to participate in a 16-hour course on personal values, learning how to integrate them into the organizational values. Employees gained personal insight into how to reflect on their personal values, set goals, and achieve success in all facets of their lives. Training centered on core values such as integrity, enthusiasm, service, and leadership. Values training also helped employees identify what they could do to become their more authentic selves and focus on how to improve their lives, which in turn can improve the lives of those around them. Once the staff understood the effect that negativity was having in the ED, the focus shifted to identifying core values and working toward a culture of ownership. This new focus on values had a positive effect on multiple aspects of the organization, one being more transparent communication with leadership. Communication was an enormous barrier between staff and management, with staff having little knowledge of current scores and goals for patient satisfaction. Leadership struggled to get staff to see the importance of the patient experience and seeing the meaning in objective patient satisfaction scores. To overcome this perpetual cycle of miscommunication, staff and management had a frank and transparent conversation about the current scores using data from patient surveys to highlight the performance on a national and peer-based level. Using graphs to show ranking compared to those of similar facilities, leadership explained what each metric meant and strategies to improve. When the staff saw the trend lines and current scores hovering around the bottom, it was a powerful motivator. Rather than solely focus on the negative, the open information sessions focused on the fact that the staff was delivering safe, high-quality care, but bad attitudes and poor communication were leading to negative patient perceptions. Some example of the comments included, “The nurses had bad attitudes and were rude to me,” and “My nurse made me feel like I was a burden.” Staff members expressed frustration that they had difficulty effectively communicating with patients. To bridge the gap, a communication framework was developed internally, and presentations rolled out in March of 2015 that were geared to both providers and staff. In these 2-hour education sessions, all ED staff and physicians were required to attend and were intermingled, so the experience was shared among all disciplines. Focused communication training for all staff, not just the newest members, also helped to set the standard for the entire unit and gave staff new tools to use. Coupled with our organizational push for personal values training, this placed the focus for staff not simply on the scores, but also on the patients behind the surveys. Staff learned how small changes to current practice could result in positive exponential gains with patient experience. Simple examples were shared, such as using the phrase “my pleasure” and how to effectively explain a procedure or process. Increasing staff participation in the planning and implementation phases also fostered our new cultural shift, helping staff own the results, and driving a desire to be informed of our progress. After all of the staff were trained, the ED staff identified the specific metrics they would like to measure monthly. Selected metrics included overall nursing ratings from patient surveys, wait times, and average daily census with dwell times. Administration began to publish the scores biweekly on social media and in print on the newly designed “brag board” to highlight department accomplishments. Patient feedback was provided in the breakroom every month, without censoring, for staff to get a better understanding of the current issues. This transparency allowed the staff to see the positive effects of change and kept the patient experience at the forefront of daily activity. The ED also implemented a frontline care innovation program to allow staff to help identify additional ways to improve communication and patient care. Leadership recognized that active participation in shared governance helped develop higher nurse engagement and subsequently improved patient experiences.4Kutney-Lee A. Germack H. Hatfield L. et al.Nurse engagement in shared governance and patient and nurse outcomes.J Nurs Adm. 2016; 46: 605-612Google Scholar The newly designed ED Improvement Council (EDIC) replaced our traditional staff meeting in favor of a shared governance council led by the interdisciplinary teams. This reorganization moved the ownership to the staff and made them invested in the results. The most notable innovation came in the utilization of social media to communicate with staff in real time through their mobile devices. Noting that more than 97% of the ED staff were on social media, the ED director came up with a proposal and successfully achieved permission to have a department level social media page for staff to communicate. The social media project helped with training initiatives, reporting of scores, and communication between staff and providers since providers were also invited to join. Continued daily reminders of the culture and patient experience initiatives also provide a constant reminder for all staff that this goal is ongoing and will continue to be our top priority. Staff enjoyed celebrating individual successes on social media because of the recognition in front of their peers, allowing them to read the comment, like it, and share it. The results of utilizing social media have been significant engagement, and interaction with staff and leadership. Similar departmental pages has been replicated across the organization. Since the shift in focus to values and communication, the ED has thrived. The ED used the National Database for Nursing Quality Indicators survey for nurse satisfaction and saw significant improvements. Previously, scores were barely meeting the mean in the best performing domains. In 2015, every domain exceeded the 90th percentile. The Mean Practice Environment Scale score, which encompasses measures from domains like “Nurse Participation in Hospital Affairs,” “Nursing Foundations for Quality of Care,” and “Nurse Manager Ability, Leadership, and Support of Nurses,” reached well above the 90th percentile and continues as of 2018 (Figure 1). Similarly, Job Enjoyment Scale, a new measure in 2015, scored well above the 90th percentile and continues to do so (Figure 2). Building on the success of the culture of ownership movement, the communication framework, and new EDIC structure resulted in improved patient experience scores. Within 2 months of implementing the initiatives, the ED was able to improve the patient experience to more than the mean for the first time in years. The ED went on to capture the highest patient experience scores ever recorded in the department, exceeding the 90th percentile (Figure 3). Staff felt the positive effects of improving patient experience and began to take even more pride and ownership in the patient experience. Provider and nurse relations also improved, leading to lower turnover and better teamwork among staff. In an internal survey, the staff’s perception of negativity in the workplace also decreased, showing 64% of respondents reported that their coworkers were more positive and more fully engaged than before the culture initiative was implemented, and 87% reported that they themselves were more positive and engaged. Perceptions on communication also improved among staff, with 93% of staff surveyed citing an improvement in overall communication.Figure 3ED Overall Composite Satisfaction by Month.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Most importantly, many of the staff have gone on to enrich their personal lives through being authentic to their values. In addition to improving their work performance, some nurses went back to school and earned advanced degrees. Others got themselves out of debt or lost a significant amount of weight with healthy living, even running marathons. The rallying cry for the ED is “Proceed until apprehended,” which is about being empowered to take the initiative and get things done. Shifting the staff mindset from fear of retribution to ownership leads to more awareness of how personal values and behaviors affect the patient’s experience of their care. When someone can reflect on how their values incorporate into actions, they are more likely to do the right thing as a result. Brandon “Kit” Bredimus, DNP, RN, CEN, CPEN, CNML, NE-BC, QMHP-CS is vice president of nursing and chief nursing officer, Midland Memorial Hospital in Midland, Texas. He can be reached at [email protected].