PERSPECTIVES ON LEADERSHIP
Hard Facts About Soft Skills One hospital unit uses a new model of care to improve communication between RNs and nursing assistants. This is the third article in a series on leadership coordinated by the American Organization of Nurse Executives (AONE) that highlights how nurses are leading change efforts in hospitals. It describes work done in conjunction with the AONE’s Care Innovation and Transformation initiative, which provides leadership development and educational opportunities to nurse managers and staff aimed at supporting nurses at the point of care in making changes to improve the quality and safety of patient care.
N
urses often think clinical skills are the most critical element of their practice. In fact, schools of nursing place great emphasis on the development of these skills, while formal training in effective collaboration and communication tends to receive less attention.1 Communication, collaboration, and delegation are frequently thought to be “soft skills”—despite that the majority of unintended medical errors involve a breakdown in communication among caregivers.2 Sicker patients, shorter lengths of stay, and multiple transfers among units heighten the necessity for effective communication among all care providers.3 Increasingly, health care is delivered through interdisciplinary partnerships, and tasks must be distributed according to individual competence and scope of practice. Nurses must be able to work and communicate with each member of the health care team, and they are increasingly expected to be skillful in delegating to assistive personnel, whose work they are ultimately responsible for. Ineffective delegation can contribute to compromised and missed care—meals that are delayed or skipped, medication administered late, opportunities to provide patient education and discharge planning missed.4 When communication and delegation are ineffective, it can lead to inaccurate information and, in turn, adverse outcomes.5 The quality of the relationship between the nurse and nursing assistant can determine how successful delegation will be and how it will ultimately affect the safety and quality of care.5 Information can be shared more effectively when trust between the RN and nursing assistant is established. In a study of the use of critical thinking by nurses in the delegation process, Bittner and Gravlin reported that nurses frequently struggled to determine if a given task was within the nursing assistant’s capabilities; moreover, nursing 64
AJN ▼ February 2014
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Vol. 114, No. 2
assistants said they often had difficulty receiving delegated work when they weren’t given complete information about the patient.6 These findings have important implications for the design of nursing care delivery models. A model that supports a strong relationship between the nurse and nursing assistant creates an environment for clearer communication and effective delegation, whereas one that calls for nursing assistants to report to multiple nurses tends to complicate delegation.6 As Bittner and Gravlin note, “The [chief nursing officer] and frontline nurse leaders have the opportunity to mitigate some of the potential variables through the implementation of a well-defined care delivery model.”6 Here we illustrate how a nursing unit at University of North Carolina (UNC) Hospitals in Chapel Hill changed its model of care to improve both nurses’ ability to delegate and communication among RNs and nursing assistants.
THE INNOVATIONS UNIT
In 2010, amid discussions about reforming the nation’s health care system, the chief nursing officer of UNC Hospitals recognized that the federal government’s implementation of the Affordable Care Act and reliance on value-based purchasing strategies in regard to hospital reimbursement would place great significance on patient satisfaction, clinical outcomes, increased efficiency, and reduced costs. A care delivery model that could enhance UNC Hospitals patients’ hospital experiences and outcomes needed to be developed and evaluated. The gastrointestinal (GI) surgery unit was subsequently chosen by the executive leadership as an “innovations unit”—the staff of which are charged with finding effective ways to provide better, faster, more affordable care to patients. An innovations unit provides ajnonline.com
By Joel D. Ray, MSN, RN, NE-BC, and Angela S. Overman, MSN, RN, CNML, NE-BC
the hospital with a platform for testing new ideas, concepts, and technology; if found to be effective, these practices are then instituted across the organization. The GI unit was chosen because the staff had established themselves as creators and early adopters of change initiatives. In early 2010, the unit had been one of the first to improve transitions of care between the inpatient and outpatient settings by ensuring that postdischarge appointments were booked—with the patient’s participation—prior to discharge. The unit was also participating in the American Organization of Nurse Executives’ two-year Care Innovation and Transformation initiative, the focus of which is to engage and empower frontline staff to make changes to their work environment that improve patient safety and quality of care.7 (See Perspectives on Leadership, February 2013, for more on this program.)
A PARTNERED PRACTICE MODEL
Six nurses and two nursing assistants typically staffed the 24-bed GI unit on a given shift. The RNs were assigned small groups of patients, whereas the nursing assistants provided supportive care to many patients. Both performed different tasks, working independently and with minimal communication and interaction. The nursing assistants often reported to as many as four nurses during a shift, and communication channels were complex and easily disrupted. The unit staff had experienced many challenges to communication and delegation because of this structure, in which they practiced parallel to each other rather than as an integrated team.
Some nursing assistants viewed delegated tasks as a ’to-do list.’ In an effort to develop a new approach to care delivery, a unit-based committee comprising RNs, nursing assistants, and the leadership conducted a literature review. The objective was to identify alternative models of care and to ultimately select one that would enable the staff to provide better, faster, and more affordable care. The staff, along with the chief nursing officer, who was engaged throughout the development and analysis of the financial impact of this model, chose to develop and implement a partnered nursing care delivery model,8 in which a nurse and nursing assistant jointly care for a group of patients. The intent [email protected]
Left to right: Lauren Bashian, a clinical support technician, and Kristen Szewczyk, a nursing assistant, participate in bedside report during shift change with RNs Beth Salzmann and Kenneth Horne. Photo by Peggy Mattingly.
was to forge a stronger relationship between the two in order to enhance communication and positively affect patients’ experiences and outcomes. As a result, unit staffing was changed to increase the budgeted hours per patient day by partnering one nursing assistant with one nurse per shift (scheduling challenges prevented the same partners from always being paired, but continuity was maintained as often as possible). The nurse-to-patient ratio was also increased, from 1:5 to 1:6. Although the hours per patient day slightly increased, overall labor costs decreased owing to a reduction in more expensive nursing care hours per patient day.
ENHANCING COMMUNICATION THROUGH TRAINING
It took approximately nine months for the GI unit’s staff to research and implement this new model of care. In that time, the staff knew that successful implementation would require that the unit’s RNs would be capable of delegating to and communicating with the nursing assistants, and that the latter would be open to receiving delegated work without feeling devalued. The previous absence of a partnership had led some nursing assistants to view delegated tasks as a “to-do list” instead of shared patient care responsibility. Nurses and nursing assistants needed to have a better understanding of and value for each other’s roles in order to appreciate each other’s perspective and the ways in which each contributes to the partnership. AJN ▼ February 2014
▼
Vol. 114, No. 2
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PERSPECTIVES ON LEADERSHIP
Thus, the unit’s leaders, staff nurses, and nursing assistants developed a four-hour training session that focused on improving communication and delegation through the use of specific techniques. The staff knew
Nurses wanted assistants to appreciate the importance of on-time medication administration. that communication style and delivery were primary factors in the success of any partnered care model, and they voiced concern that autocratic communication styles would diminish the effectiveness of the partnerships they were hoping to form. There was also awareness that a certain level of directness and clarity would be required to ensure that delegated tasks were understood and completed appropriately. The agenda for the training session focused on role clarification, creating community norms, and the essential elements of delegation. Experts from the hospital’s Department of Learning and Organizational Development assisted the unit’s leadership in the design and management of the training session, providing assistance with curriculum development and evaluations. This training was paid for through the unit’s education budget. Role clarification. In order to clarify everyone’s role on the unit, staff members were asked during the training session, “What do you most want your partner to know about your role that you believe she or he does not understand?” The unit’s nurses responded that they wanted the assistants to know that the RN is ultimately responsible for the patient, and that many standards must be met to fulfill accreditation requirements. They also wanted assistants to appreciate the volume of medications and the importance of on-time medication administration, and to understand that by completing other essential patient care tasks, they were enabling the RNs to focus on medication delivery. The nursing assistants noted that they felt “out of the loop” regarding patient information and updates, and unsure of their contribution to patient outcomes. Understanding the concerns and views of their partners provided nurses and nursing assistants with a framework for building their partnership. Creating community norms. During the training session, the staff discussed community norms that they believed would enhance the unit’s culture and improve patient care. These norms define the behaviors that are most desirable and conducive to the provision 66
AJN ▼ February 2014
▼
Vol. 114, No. 2
of quality care, including being appreciative, responsible, dependable, mindful of others, approachable, and accountable (see Community Norms). These norms also highlight the staff’s commitment to making the entire unit a “no passing zone,”9 in which no staff member, regardless of her or his patient assignment or role on the team, passes by a patient call light, iv alarm, or any other indication that a patient needs assistance. Every team member agreed to accept and hold each other accountable to these community norms, which became a powerful tool to improving both safety and the patient’s experience. The staff also discussed how these norms could be implemented in daily work; for example, by expressing appreciation for the completion of delegated tasks or by tactfully providing feedback when delegated tasks weren’t completed as needed. All staff members signed and kept a copy of the community norms to formalize their commitment to their work relationships.
Community Norms Behaviors the GI staff believes are desirable and conducive to the provision of quality care. •• Be appreciative by using kind words, such as “please,” “thank you,” and “good job.” •• Be responsible and dependable by completing your work proactively. •• Be mindful of one another’s workload—across disciplines, from the RNs to the nursing assistants and health unit coordinators—and offer to help. •• Apply principles of effective communication by (1) listening without interrupting, (2) making eye contact, and (3) allowing time for a response, questions, and clarification. •• Be approachable by being aware of your body language and facial expressions, and by not having defensive reactions. •• Be accountable for your own actions. •• Teach but don’t blame. Give constructive feedback. •• Speak the truth, but speak it gently. Sometimes, in our passions, we are fierce. •• Work as a team. Remember the “no passing zone,” regardless of discipline. Each nurse isn’t responsible for only six patients—we, as a team, have 24 patients. There is no “I” in team!
ajnonline.com
Table 1. Patient Satisfaction Before and After Implementation of the Partnered Practice Model Preimplementation
Postimplementation
Mean Score
Percentilea
Mean Score
Percentilea
Satisfaction with nursing
89.9
57
92
95
Prompt response to calls
88.1
81
89.6
96
Nurses kept you informed
88.1
49
90.9
96
Pain control
87.4
47
89.4
92
Overall
86.3
51
88.5
91
a
Ranking is relative to other U.S. hospitals with more than 600 beds.
Essential elements of delegation. Once the RNs and nursing assistants had developed a better appreciation of each other’s role, the process of delegation was more closely examined. Delegation is an integral component of the relationship between an RN and a nursing assistant. Although nurses may delegate the accomplishment of a certain task, they retain accountability for its completion and quality.10 Clear, concise, and complete communication is at the core of delegation. This communication must begin at the start of the shift, when both the nurse and nursing assistant participate in bedside report, planning how they will work together during the shift and creating communication “checkpoints” for validating progress on delegated tasks. During these checkpoints, which occur every two to three hours, the partners meet to discuss their progress on the plan of care and any changes in the patient’s health status that require reassessing priorities. In the training session, staff members were encouraged to develop an apprentice-style relationship in which knowledge and skills are routinely transferred from the nurse to the nursing assistant. This exchange serves to increase the clinical knowledge and skill of the nursing assistant, which ultimately makes the partnership stronger. In an effort to help the staff better conceptualize the apprentice-style relationship, the unit’s clinical nurse leaders led by example, demonstrating how to pass on knowledge and skills to nursing assistants during the course of daily patient care. For example, they discussed with their nursingassistant partners the physiology behind GI surgeries and the associated symptoms the patient may experience, as well as how to monitor the patient’s progress relative to the individualized plan of care.
SATISFACTION, QUALITY, AND COST
The training session and the establishment of community norms had an observable effect on patient care, [email protected]
unit activities, and the work environment. Nurses and nursing assistants began participating in bedside report together, collaboratively planning patient care, and defining individual and collective responsibilities. The nursing staff’s greatest interest was in the effect of these changes on clinical outcomes and patient satisfaction on the GI unit. Data gathered by Press Ganey for UNC Hospitals show improvement in mean patient satisfaction scores and percentile ranking relative to other hospitals with more than 600 beds. This improvement was seen in four measures: satisfaction with nursing, prompt response to calls, nurses keeping patients informed, and pain control (see Table 1).
Clear, concise, and complete communication is at the core of delegation. The impact of improved communication and delegation may have also played a part in the unit’s improved employee satisfaction scores. Employee satisfaction, as measured by Morehead Associates, now part of Press Ganey, was greater among the unit’s entire staff, including nurses and assistive personnel, in 2012 compared with 2011. Survey results categorize satisfaction levels in terms of tiers, with tier 1 representing the highest performing work centers nationally for staff engagement and satisfaction. Tier 1 employee satisfaction was achieved on the GI unit 12 months after the May 2012 implementation of the new care model. Clinical outcomes were also monitored before and after implementation of the new model. The rate of falls was reduced from 1.67 to 1.52 per 1,000 patient days, and the rates of catheter-associated bloodstream and urinary tract infections decreased from 1 AJN ▼ February 2014
▼
Vol. 114, No. 2
67
PERSPECTIVES ON LEADERSHIP
to 0 and 2.71 to 2.35 per 1,000 patient days, respectively. Although these findings cannot be singularly attributed to an improved relationship between the nurses and nursing assistants, it’s possible that they resulted from improved communication and understanding of the plan of care. Pfrimmer reported that strong teamwork in care delivery is an important aspect of patient safety, and that effective communication reduces the risk of error.2
Effective communication and delegation can positively affect clinical outcomes and the patient experience. The GI innovations unit at UNC Hospitals is expected to set a goal, implement an intervention, and compare pre- and postimplementation data. The intervention is considered effective if the goal is reached. This is unlike formal studies that have systematic sampling and control for independent variables. Thus, while the assessment of this new model of care on the GI unit does not provide definitive cause-and-effect data, the important goal of improvement in nursing care, as evaluated by patients and the use of key quality measures, was achieved. These improvements are operationally significant.
IMPLICATIONS FOR PRACTICE
The lack of clarity in the literature regarding the effect of communication on patient outcomes is indicative of the need for further research.11 The establishment of the innovations unit’s community norms—such as clear communication, appreciative language, approachability, teamwork, accountability, and respectfulness—may have facilitated the creation of an environment that supports partnered practice. These norms are a reflection of values and behaviors more than of any style of communication. Therefore, hospitals, which have previously placed great emphasis on the relationship between safety and patient outcomes, should perhaps also focus on the way the broader organizational culture affects patient satisfaction and outcomes. The organizational culture is the foundation upon which effective communication can be built, and an organization that values respectfulness, accountability, teamwork, and avoiding blame is likely to foster a work environment in which medical errors can be reduced. 68
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The UNC Hospitals nursing leadership established a culture of collaboration and teamwork by ensuring that every role was clarified, and every staff member valued. Staff was better able to participate in delegating and receiving delegated work once this had been established. An apprentice-style partnership between the nurse and nursing assistant may positively affect the care of patients through the exchange of knowledge during routine care delivery. There is a need for more research into this relationship and its effects on the patient’s experience and clinical outcomes, especially because of the increased use of value-based purchasing strategies by employers and the federal government. In practice, it’s not difficult to appreciate that effective communication and delegation can positively affect clinical outcomes and the patient experience. These so-called soft skills can also provide a better work environment that contributes to the staff’s sense of well-being. ▼ Joel D. Ray is a colonel (ret.) in the U.S. Air Force Nurse Corps and the director of surgery service at University of North Carolina (UNC) Hospitals in Chapel Hill. Angela S. Overman is the nurse manager of acute GI surgery at UNC Hospitals. Contact author: Angela S. Overman, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Leonard M, et al. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13 Suppl 1:i85-i90. 2. Pfrimmer D. Teamwork and communication. J Contin Educ Nurs 2009;40(7):294-5. 3. Anthony MK, Preuss G. Models of care: the influence of nurse communication on patient safety. Nurs Econ 2002;20(5):209-15, 248. 4. Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual 2006;21(4):306-13. 5. Anthony MK, Preuss G. Mindful communication: a novel approach to improving delegation and increasing patient safety. Online J Issues Nurs 2010;15(2). http://www. nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Vol152010/ No2May2010/Mindful-Communication-and-Delegation. html. 6. Bittner NP, Gravlin G. Critical thinking, delegation, and missed care in nursing practice. J Nurs Adm 2009;39(3): 142-6. 7. Association of Nurse Executives (AONE). Care innovation and transformation. 2012. http://www.aone.org/resources/ CCIT/ccit.shtml. 8. Potter P, Mueller JR. How well do you know your patients? Nurs Manage 2007;38(2):40-8. 9. Tonges M, Ray J. Translating caring theory into practice: the Carolina Care Model. J Nurs Adm 2011;41(9):374-81. 10. Curtis E, Nicholl H. Delegation: a key function of nursing. Nurs Manag (Harrow) 2004;11(4):26-31. 11. Street RL, Jr., et al. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns 2009;74(3):295-301. ajnonline.com
Hard Facts About Soft Skills One hospital unit uses a new model of care to improve communication between RNs and nursing assistants. This is the third article in a series on leadership coordinated by the American Organization of Nurse Executives (AONE) that highlights how nurses are leading change efforts in hospitals. It describes work done in conjunction with the AONE’s Care Innovation and Transformation initiative, which provides leadership development and educational opportunities to nurse managers and staff aimed at supporting nurses at the point of care in making changes to improve the quality and safety of patient care.
N
urses often think clinical skills are the most critical element of their practice. In fact, schools of nursing place great emphasis on the development of these skills, while formal training in effective collaboration and communication tends to receive less attention.1 Communication, collaboration, and delegation are frequently thought to be “soft skills”—despite that the majority of unintended medical errors involve a breakdown in communication among caregivers.2 Sicker patients, shorter lengths of stay, and multiple transfers among units heighten the necessity for effective communication among all care providers.3 Increasingly, health care is delivered through interdisciplinary partnerships, and tasks must be distributed according to individual competence and scope of practice. Nurses must be able to work and communicate with each member of the health care team, and they are increasingly expected to be skillful in delegating to assistive personnel, whose work they are ultimately responsible for. Ineffective delegation can contribute to compromised and missed care—meals that are delayed or skipped, medication administered late, opportunities to provide patient education and discharge planning missed.4 When communication and delegation are ineffective, it can lead to inaccurate information and, in turn, adverse outcomes.5 The quality of the relationship between the nurse and nursing assistant can determine how successful delegation will be and how it will ultimately affect the safety and quality of care.5 Information can be shared more effectively when trust between the RN and nursing assistant is established. In a study of the use of critical thinking by nurses in the delegation process, Bittner and Gravlin reported that nurses frequently struggled to determine if a given task was within the nursing assistant’s capabilities; moreover, nursing 64
AJN ▼ February 2014
▼
Vol. 114, No. 2
assistants said they often had difficulty receiving delegated work when they weren’t given complete information about the patient.6 These findings have important implications for the design of nursing care delivery models. A model that supports a strong relationship between the nurse and nursing assistant creates an environment for clearer communication and effective delegation, whereas one that calls for nursing assistants to report to multiple nurses tends to complicate delegation.6 As Bittner and Gravlin note, “The [chief nursing officer] and frontline nurse leaders have the opportunity to mitigate some of the potential variables through the implementation of a well-defined care delivery model.”6 Here we illustrate how a nursing unit at University of North Carolina (UNC) Hospitals in Chapel Hill changed its model of care to improve both nurses’ ability to delegate and communication among RNs and nursing assistants.
THE INNOVATIONS UNIT
In 2010, amid discussions about reforming the nation’s health care system, the chief nursing officer of UNC Hospitals recognized that the federal government’s implementation of the Affordable Care Act and reliance on value-based purchasing strategies in regard to hospital reimbursement would place great significance on patient satisfaction, clinical outcomes, increased efficiency, and reduced costs. A care delivery model that could enhance UNC Hospitals patients’ hospital experiences and outcomes needed to be developed and evaluated. The gastrointestinal (GI) surgery unit was subsequently chosen by the executive leadership as an “innovations unit”—the staff of which are charged with finding effective ways to provide better, faster, more affordable care to patients. An innovations unit provides ajnonline.com
By Joel D. Ray, MSN, RN, NE-BC, and Angela S. Overman, MSN, RN, CNML, NE-BC
the hospital with a platform for testing new ideas, concepts, and technology; if found to be effective, these practices are then instituted across the organization. The GI unit was chosen because the staff had established themselves as creators and early adopters of change initiatives. In early 2010, the unit had been one of the first to improve transitions of care between the inpatient and outpatient settings by ensuring that postdischarge appointments were booked—with the patient’s participation—prior to discharge. The unit was also participating in the American Organization of Nurse Executives’ two-year Care Innovation and Transformation initiative, the focus of which is to engage and empower frontline staff to make changes to their work environment that improve patient safety and quality of care.7 (See Perspectives on Leadership, February 2013, for more on this program.)
A PARTNERED PRACTICE MODEL
Six nurses and two nursing assistants typically staffed the 24-bed GI unit on a given shift. The RNs were assigned small groups of patients, whereas the nursing assistants provided supportive care to many patients. Both performed different tasks, working independently and with minimal communication and interaction. The nursing assistants often reported to as many as four nurses during a shift, and communication channels were complex and easily disrupted. The unit staff had experienced many challenges to communication and delegation because of this structure, in which they practiced parallel to each other rather than as an integrated team.
Some nursing assistants viewed delegated tasks as a ’to-do list.’ In an effort to develop a new approach to care delivery, a unit-based committee comprising RNs, nursing assistants, and the leadership conducted a literature review. The objective was to identify alternative models of care and to ultimately select one that would enable the staff to provide better, faster, and more affordable care. The staff, along with the chief nursing officer, who was engaged throughout the development and analysis of the financial impact of this model, chose to develop and implement a partnered nursing care delivery model,8 in which a nurse and nursing assistant jointly care for a group of patients. The intent [email protected]
Left to right: Lauren Bashian, a clinical support technician, and Kristen Szewczyk, a nursing assistant, participate in bedside report during shift change with RNs Beth Salzmann and Kenneth Horne. Photo by Peggy Mattingly.
was to forge a stronger relationship between the two in order to enhance communication and positively affect patients’ experiences and outcomes. As a result, unit staffing was changed to increase the budgeted hours per patient day by partnering one nursing assistant with one nurse per shift (scheduling challenges prevented the same partners from always being paired, but continuity was maintained as often as possible). The nurse-to-patient ratio was also increased, from 1:5 to 1:6. Although the hours per patient day slightly increased, overall labor costs decreased owing to a reduction in more expensive nursing care hours per patient day.
ENHANCING COMMUNICATION THROUGH TRAINING
It took approximately nine months for the GI unit’s staff to research and implement this new model of care. In that time, the staff knew that successful implementation would require that the unit’s RNs would be capable of delegating to and communicating with the nursing assistants, and that the latter would be open to receiving delegated work without feeling devalued. The previous absence of a partnership had led some nursing assistants to view delegated tasks as a “to-do list” instead of shared patient care responsibility. Nurses and nursing assistants needed to have a better understanding of and value for each other’s roles in order to appreciate each other’s perspective and the ways in which each contributes to the partnership. AJN ▼ February 2014
▼
Vol. 114, No. 2
65
PERSPECTIVES ON LEADERSHIP
Thus, the unit’s leaders, staff nurses, and nursing assistants developed a four-hour training session that focused on improving communication and delegation through the use of specific techniques. The staff knew
Nurses wanted assistants to appreciate the importance of on-time medication administration. that communication style and delivery were primary factors in the success of any partnered care model, and they voiced concern that autocratic communication styles would diminish the effectiveness of the partnerships they were hoping to form. There was also awareness that a certain level of directness and clarity would be required to ensure that delegated tasks were understood and completed appropriately. The agenda for the training session focused on role clarification, creating community norms, and the essential elements of delegation. Experts from the hospital’s Department of Learning and Organizational Development assisted the unit’s leadership in the design and management of the training session, providing assistance with curriculum development and evaluations. This training was paid for through the unit’s education budget. Role clarification. In order to clarify everyone’s role on the unit, staff members were asked during the training session, “What do you most want your partner to know about your role that you believe she or he does not understand?” The unit’s nurses responded that they wanted the assistants to know that the RN is ultimately responsible for the patient, and that many standards must be met to fulfill accreditation requirements. They also wanted assistants to appreciate the volume of medications and the importance of on-time medication administration, and to understand that by completing other essential patient care tasks, they were enabling the RNs to focus on medication delivery. The nursing assistants noted that they felt “out of the loop” regarding patient information and updates, and unsure of their contribution to patient outcomes. Understanding the concerns and views of their partners provided nurses and nursing assistants with a framework for building their partnership. Creating community norms. During the training session, the staff discussed community norms that they believed would enhance the unit’s culture and improve patient care. These norms define the behaviors that are most desirable and conducive to the provision 66
AJN ▼ February 2014
▼
Vol. 114, No. 2
of quality care, including being appreciative, responsible, dependable, mindful of others, approachable, and accountable (see Community Norms). These norms also highlight the staff’s commitment to making the entire unit a “no passing zone,”9 in which no staff member, regardless of her or his patient assignment or role on the team, passes by a patient call light, iv alarm, or any other indication that a patient needs assistance. Every team member agreed to accept and hold each other accountable to these community norms, which became a powerful tool to improving both safety and the patient’s experience. The staff also discussed how these norms could be implemented in daily work; for example, by expressing appreciation for the completion of delegated tasks or by tactfully providing feedback when delegated tasks weren’t completed as needed. All staff members signed and kept a copy of the community norms to formalize their commitment to their work relationships.
Community Norms Behaviors the GI staff believes are desirable and conducive to the provision of quality care. •• Be appreciative by using kind words, such as “please,” “thank you,” and “good job.” •• Be responsible and dependable by completing your work proactively. •• Be mindful of one another’s workload—across disciplines, from the RNs to the nursing assistants and health unit coordinators—and offer to help. •• Apply principles of effective communication by (1) listening without interrupting, (2) making eye contact, and (3) allowing time for a response, questions, and clarification. •• Be approachable by being aware of your body language and facial expressions, and by not having defensive reactions. •• Be accountable for your own actions. •• Teach but don’t blame. Give constructive feedback. •• Speak the truth, but speak it gently. Sometimes, in our passions, we are fierce. •• Work as a team. Remember the “no passing zone,” regardless of discipline. Each nurse isn’t responsible for only six patients—we, as a team, have 24 patients. There is no “I” in team!
ajnonline.com
Table 1. Patient Satisfaction Before and After Implementation of the Partnered Practice Model Preimplementation
Postimplementation
Mean Score
Percentilea
Mean Score
Percentilea
Satisfaction with nursing
89.9
57
92
95
Prompt response to calls
88.1
81
89.6
96
Nurses kept you informed
88.1
49
90.9
96
Pain control
87.4
47
89.4
92
Overall
86.3
51
88.5
91
a
Ranking is relative to other U.S. hospitals with more than 600 beds.
Essential elements of delegation. Once the RNs and nursing assistants had developed a better appreciation of each other’s role, the process of delegation was more closely examined. Delegation is an integral component of the relationship between an RN and a nursing assistant. Although nurses may delegate the accomplishment of a certain task, they retain accountability for its completion and quality.10 Clear, concise, and complete communication is at the core of delegation. This communication must begin at the start of the shift, when both the nurse and nursing assistant participate in bedside report, planning how they will work together during the shift and creating communication “checkpoints” for validating progress on delegated tasks. During these checkpoints, which occur every two to three hours, the partners meet to discuss their progress on the plan of care and any changes in the patient’s health status that require reassessing priorities. In the training session, staff members were encouraged to develop an apprentice-style relationship in which knowledge and skills are routinely transferred from the nurse to the nursing assistant. This exchange serves to increase the clinical knowledge and skill of the nursing assistant, which ultimately makes the partnership stronger. In an effort to help the staff better conceptualize the apprentice-style relationship, the unit’s clinical nurse leaders led by example, demonstrating how to pass on knowledge and skills to nursing assistants during the course of daily patient care. For example, they discussed with their nursingassistant partners the physiology behind GI surgeries and the associated symptoms the patient may experience, as well as how to monitor the patient’s progress relative to the individualized plan of care.
SATISFACTION, QUALITY, AND COST
The training session and the establishment of community norms had an observable effect on patient care, [email protected]
unit activities, and the work environment. Nurses and nursing assistants began participating in bedside report together, collaboratively planning patient care, and defining individual and collective responsibilities. The nursing staff’s greatest interest was in the effect of these changes on clinical outcomes and patient satisfaction on the GI unit. Data gathered by Press Ganey for UNC Hospitals show improvement in mean patient satisfaction scores and percentile ranking relative to other hospitals with more than 600 beds. This improvement was seen in four measures: satisfaction with nursing, prompt response to calls, nurses keeping patients informed, and pain control (see Table 1).
Clear, concise, and complete communication is at the core of delegation. The impact of improved communication and delegation may have also played a part in the unit’s improved employee satisfaction scores. Employee satisfaction, as measured by Morehead Associates, now part of Press Ganey, was greater among the unit’s entire staff, including nurses and assistive personnel, in 2012 compared with 2011. Survey results categorize satisfaction levels in terms of tiers, with tier 1 representing the highest performing work centers nationally for staff engagement and satisfaction. Tier 1 employee satisfaction was achieved on the GI unit 12 months after the May 2012 implementation of the new care model. Clinical outcomes were also monitored before and after implementation of the new model. The rate of falls was reduced from 1.67 to 1.52 per 1,000 patient days, and the rates of catheter-associated bloodstream and urinary tract infections decreased from 1 AJN ▼ February 2014
▼
Vol. 114, No. 2
67
PERSPECTIVES ON LEADERSHIP
to 0 and 2.71 to 2.35 per 1,000 patient days, respectively. Although these findings cannot be singularly attributed to an improved relationship between the nurses and nursing assistants, it’s possible that they resulted from improved communication and understanding of the plan of care. Pfrimmer reported that strong teamwork in care delivery is an important aspect of patient safety, and that effective communication reduces the risk of error.2
Effective communication and delegation can positively affect clinical outcomes and the patient experience. The GI innovations unit at UNC Hospitals is expected to set a goal, implement an intervention, and compare pre- and postimplementation data. The intervention is considered effective if the goal is reached. This is unlike formal studies that have systematic sampling and control for independent variables. Thus, while the assessment of this new model of care on the GI unit does not provide definitive cause-and-effect data, the important goal of improvement in nursing care, as evaluated by patients and the use of key quality measures, was achieved. These improvements are operationally significant.
IMPLICATIONS FOR PRACTICE
The lack of clarity in the literature regarding the effect of communication on patient outcomes is indicative of the need for further research.11 The establishment of the innovations unit’s community norms—such as clear communication, appreciative language, approachability, teamwork, accountability, and respectfulness—may have facilitated the creation of an environment that supports partnered practice. These norms are a reflection of values and behaviors more than of any style of communication. Therefore, hospitals, which have previously placed great emphasis on the relationship between safety and patient outcomes, should perhaps also focus on the way the broader organizational culture affects patient satisfaction and outcomes. The organizational culture is the foundation upon which effective communication can be built, and an organization that values respectfulness, accountability, teamwork, and avoiding blame is likely to foster a work environment in which medical errors can be reduced. 68
AJN ▼ February 2014
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Vol. 114, No. 2
The UNC Hospitals nursing leadership established a culture of collaboration and teamwork by ensuring that every role was clarified, and every staff member valued. Staff was better able to participate in delegating and receiving delegated work once this had been established. An apprentice-style partnership between the nurse and nursing assistant may positively affect the care of patients through the exchange of knowledge during routine care delivery. There is a need for more research into this relationship and its effects on the patient’s experience and clinical outcomes, especially because of the increased use of value-based purchasing strategies by employers and the federal government. In practice, it’s not difficult to appreciate that effective communication and delegation can positively affect clinical outcomes and the patient experience. These so-called soft skills can also provide a better work environment that contributes to the staff’s sense of well-being. ▼ Joel D. Ray is a colonel (ret.) in the U.S. Air Force Nurse Corps and the director of surgery service at University of North Carolina (UNC) Hospitals in Chapel Hill. Angela S. Overman is the nurse manager of acute GI surgery at UNC Hospitals. Contact author: Angela S. Overman, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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