Nora Warshawsky, PhD, RN, FAAN
University of Central Florida
$50,000 grant in honor of AONL’s 50th Anniversary (2017)
Evaluating the Impact of Nurse Manager Job Design and Practice Environment on Achieving the Quadruple Aim
Healthcare leaders are responsible for setting the strategic direction of healthcare organizations; therefore, responsible for enacting the Institute of Healthcare Improvement’s (IHI) Quadruple Aim. Nurse managers create the environments necessary to achieve quality patient experiences and outcomes, reducing costs of care, and creating high performance teams at the point of care. Thus, leveraging nurse managers to advance the Quadruple Aim is critical to organizational success. Given the wide variation in job design and the dearth of evidence on effective job design and practice environments needed to maximize nurse managers’ job performance, we propose to determine which aspects of job design and practice environments assist nurse managers in achieving the Quadruple Aim. This study aligns with AONE’s priority to understand the impact of nursing leadership on achieving the IHI Quadruple Aim by determining effective job design of the nurse manager role.
The cross-sectional study design will use an electronical survey of nurse managers to assess their role preparation, self-assessed competence, job design, practice environment (using the Nurse Manager Practice Environment Scale), and nurse manager demographics. Press Ganey is administering the survey in 70 hospitals to nurse managers responsible for units that provide patient care and participated in the nurse survey in the past two years. The Nurse Manager survey data will be linked to unit-level RN survey data including the following measures: the Practice Environment Scale of the Nursing Work Index (PES-NWI), intent to stay in their position, job enjoyment, RN reported quality of care, and missed nursing care. Descriptive statistics will be used to examine and describe nurse manager practice environment, span of control, and position support. Multilevel mediation modelling will be used to test our hypotheses. Recommendations for improving job design and practice environments to support effective nurse managers will be made based on our findings.
Jennifer Rainer, RN, PhD candidate
Saint Louis University
$12,475 small grant made possible by a generous gift from Atrium Health in honor of CHS Nurses.
Speaking up or Remaining Silent: Understanding the Influences on Nurses When Patients are at Risk
RNs leave the profession prematurely because of high physical demands and burnout. One cause of burnout is moral distress resulting from situations where RNs know the right thing to do, but organizational constraints (e.g., lack of managerial support to challenge physicians’ end-of-life decisions) create barriers to speaking up. Failure to speak up (i.e., using one’s voice to share information or alert those in authority) contributes to patient harm. Conversely, when RNs speak up, they are demonstrating moral courage, which strengthens organizational culture and enhances patient safety. While moral courage encompasses many behaviors and situations, speaking up is specific to verbal advocacy at a critical time. The principal investigator (PI) previously published a theory synthesis which resulted in a speaking up model. She found that speaking up is primarily influenced by organizational culture, personal culture, and workforce generation. Further, speaking up can lead to moral courage; failure to speak up can lead to moral distress. Moral courage and distress have been well explored in the literature, however, there is little evidence regarding what influences RNs to speak-up or remain silent. To address this gap, the purpose of this study is to understand the relationships among factors that influence RNs speaking up and how speaking up is related to moral courage and distress. The aims are to (1) explore the factors that influence RNs speaking up and (2) test the model that workforce generation, personal culture, and organizational culture influence speaking-up behavior and moral courage and distress. These aims will be accomplished through an on-line quantitative survey for bedside nurses, consisting of the Safety Attitudes Questionnaire, Moral Distress Scale Revised, and Moral Courage Scale, reflecting the constructs of the PI’s model. RNs will be recruited through state and national nursing associations to ensure diversity in personal culture, organizational culture, and workforce generation. Data analysis will include descriptive statistics (to identify violations of assumptions), Pearson correlations (to address aim 1), and structural equation modeling (to address aim 2). Limitations include self-reporting inflation (which will be mitigated with anonymity), recall error (mitigated by excluding RNs without current bedside experience), and cross-sectional ambiguity regarding temporal precedence. This design is an important first step in understanding the factors that contribute to speaking up or remaining silent. The findings, aligned with AONE strategic priority #3, will help RNs to better provide safe, quality care through delivery systems grounded in healthy practice environments.
Eva Keeling, MSN, RN, NE-BC and Research Team
Inova Health Care
$40,000 Patient Safety and Technology Grant underwritten by a generous gift from AvaSure, LLC
Impact of a Leadership Bundle on Technology Acceptance of Remote Visual Monitoring for Patient Safety
A leading challenge for healthcare organizations is the prevention of patient falls. An aging population with comorbidities contributes to an increased risk for falls. Among the top 10 sentinel events reported to The Joint Commission are falls with serious injuries (Chu, 2017). In the United States alone it is estimated that approximately one million patients fall annually, with around 30% of these falls resulting in harm, and up to 6% of those leading to serious harm (Brown, 2015). Those at high risk for falls should be constantly monitored for changes in physical ability (Tsai, et al., 2014) In 2015, Centers for Medicare and Medicaid Services (CMS) began to curtail reimbursements to hospitals with respect to risk-adjusted hospital acquired conditions and quality measures, including falls leading to serious injuries (CMS, 2008). Hospitals now absorb the cost of caring for patients who have sustained an injury from a fall (Kuhn, 2008).
Many healthcare organizations have turned to bedside sitters or companions to mitigate falls at significant cost without conclusive evidence that sitters are effective in preventing falls (Adams & Kaplow, 2013). More recently, facilities are looking to video monitoring technology to reduce costs associated with bedside sitters and still keep patients safe. Initial research on video monitoring looks promising. Sand- Jecklin et al. reported a 28.5% reduction in both falls and injuries, as well as a 23.2% reduction in sitter shifts, when they implemented remote video monitoring (Sand-Jecklin, Johnson, & Tylka, 2016). A second study reported similar findings, reporting estimated savings of more than two million dollars in staffing costs over a two-year period (Burtson & Vento, 2015).
Remote video monitoring (RVM) was introduced to our acute-care facility eight months ago in response to increasing costs for up to 18 bedside sitters per shift and difficulty meeting all the perceived needs for sitters. This technology allows two on-site trained technicians to continuously monitor up to 18 patients at a time. Before implementing the technology, all clinical staff completed an online education module as well as unit-based in-services. Policies and patient selection protocols already available from our sister facilities were adapted to our specific hospital and reviewed with staff and unit leaders. We introduced the technology one unit at a time, waiting a week before moving to the next unit. During the initial introduction of the cameras to the patients and staff, we maintained both cameras and bedside sitters in the room for a few hours to allow staff to develop trust in the technology. During the transition period the bedside sitter only acted if the patient did not respond to redirection from the tele sitter.
Over the months, some of our nursing units have embraced the technology, while other units, mainly our critical care units, remain resistant. Some nurses believe that bedside sitters are the only effective intervention to prevent falls and other adverse patient safety events. Literature shows that this is a widespread belief that is not limited to our setting (Burtson & Vento, 2015). Some clinical staff claim that RVM increases their work load because they are called to patient rooms more frequently than when there is a bedside sitter. Staff at times use “workarounds” to minimize RVM use by requesting a sitter even though the patient doesn’t qualify for one according to the risk assessment protocol, or staff reassign Clinical Technicians to function as sitters. The goal of this study is to evaluate concerns and barriers to use of RVM by nursing staff, and work with nurse leaders to develop, implement and test the benefit of a structured intervention bundle to improve acceptance and implementation of RVM technology while preventing falls.
Diana Meyer, DNP, RN, NEA-BC, FAEN, and Research Team
In memory of Susan Cline, DNP, RN, NEA-BC
St. Luke’s Health System
$50,000 Sustainable Nursing Workforce Development Grant made possible by a generous gift from the Versant Center for the Advancement of Nursing®.
Cultivating Joy and Resilience in Nursing Through a Practice Playbook.
Resilience is defined as an individual's or organization's ability to respond and recover in adversity. Transformational nurse leaders must demonstrate, develop, and implement resilience strategies in the teams that they lead. The evidence suggests that strengthening resiliency will improve nurse engagement and well-being, care quality, and patient safety. The purpose of this study is to assess whether nurse leaders' implementation of a practice playbook improves resilience in direct care nurses in a health system that includes nine hospitals and 280 ambulatory clinics. The study investigators will develop and implement a Resilience Playbook. The Playbook will include a menu of strategies for leaders and staff to choose from, including structured stress-reduction programs, writing, yoga, salons and daily gratitude practices. The Resilience Playbooks will be implemented with nurses at all levels of the organization, new graduate registered nurses, and BSN students during their leadership course. The impact will be measured by the Conor-Davidson Resilience Scale (CD-RISC). Following IRB approval, pre and post-implementation surveys will be distributed to registered nurses providing direct patient care over fifty percent of their work time. Data will be analyzed using independent t testing.
Nancy Hoffart, PhD, RN
University of North Carolina at Greensboro
$7,550 Sustainable Nursing Workforce Development Grant made possible by a generous gift from the Versant Center for the Advancement of Nursing®.
Developing a Measure of Implementation Fidelity for a Nurse Residency Program.
Nurse residency programs (NRPs) have been shown to ease newly licensed registered nurses’ (NLRNs) transition to practice, increase their work satisfaction, and improve their retention. Residency programs offered by hospitals have several common elements, yet differences exist, such as program length. Because they have many elements, NRPs can be challenging to initiate making it difficult to ensure implementation fidelity, defined as the extent to which a program is implemented as designed. Studies that report a direct link between particular residency elements and desired outcomes were not found. We propose to develop a tool that can be used to measure implementation fidelity of NRP programs. Development of the tool is an important step in building the evidence base about NRPs.
The tool will be developed in three phases guided by an implementation fidelity framework. In Phase 1, items to assess the implementation fidelity of six elements commonly found in nurse residency programs will be developed using data gathered through interviews with nurse leaders involved in delivering an NRP. In Phase 2, we will use a national panel of nurses who have expertise in delivering NRPs to quantitatively establish content validity of the tool and samples of Novant Health nurses to assess face validity and feasibility (time to complete, administration logistics, etc.). In Phase 3, initial pilot testing will be conducted for evaluating implementation fidelity of one NRP. Over the three phases a tool that can be used in future studies of NRPs will be developed and refined. Having such a tool will be useful in future studies that aim to substantiate both the efficacy and the effectiveness of NRPs on a variety of outcomes for newly licensed registered nurses and healthcare organization.
John Whitcomb, PhD and Lori Stanley, DNP, RN, NEA-BC, CENP
Clemson School of Nursing
$6,508 Sustainable Nursing Workforce Development Grant made possible by a generous gift from the Versant Center for the Advancement of Nursing®.
Innovative Teaching and Learning: Key Metrics of an Undergraduate Nursing Academic and Clinical Learning Environment
Purpose: A newly established education and practice collaborative doubled the numbers of baccalaureate registered nursing students admitted to the nursing education program. The purpose of this study is to investigate key metrics during the first two crucial launch years: (a) the perceptions of the learning environment – using the Quality Clinical Placement Evaluation (QCPE) ; (b) the percentage of student clinical placements at partnership clinical sites in relation to requested clinical placements; (c) the concurrent completion of the healthcare service’s new hire residency skills checklists as part of the nursing program of study (d) the change in the students’ critical thinking scores-- the ETS proficiency profile (5) the financial expenditures for travel nurses, RN overtime, and RN orientation.
Background and Significance: The “Future of Nursing” and the “Manatt” reports identified the benefits of innovative academic and clinical learning partnerships to build a pipeline of bedside nurses. South Carolina is 44th worst state in health rankings and predicted to have the 4th highest nursing shortage by 2030.
Methods: Using a prospective, descriptive, correlational research design surveys of perceptions of clinical environments and critical thinking and other key data will be analyzed at three intervals during the students’ final semesters.
Implications: Analysis of key metrics support the nursing leaders in health care systems and in academia to capture the effects of clinical placements, make comparisons over time, and underscores the importance of the quality clinical experience during undergraduate nursing degrees, so important to the development of students as beginning health professionals.
Yolanda Keys, DHA, RN, NEA-BC, EDAC
Texas A&M University
$7,310 Sustainable Nursing Workforce Development Grant made possible by a generous gift from the Versant Center for the Advancement of Nursing®.
Mitigating the Adverse Effects of 12-hour Shifts: Nurse Leaders’ Perspectives
In spite of evidence that long shifts are problematic, the use of 12-hour shifts in acute care nursing has become the norm. Although the scheduling convenience of 12-hour shifts may be perceived as a benefit for both nurses and nurse leaders, the strain of long shifts can lead to adverse outcomes for nurses, organizations and patients. Nurses who work shifts greater than or equal to 12-hours are at increased risk for injury, fatigue, and job stress, which predisposes them to burnout and a desire to leave their position or the profession. Organizations pay the price for burnout related turnover in the form of replacement costs upwards of $25,000 per nurse. Patients who are cared for by nurses working long shifts have higher levels of dissatisfaction and may experience missed care interventions, sub-optimal outcomes, and greater than expected risk of mortality.
The Job Demands-Resources model is used to frame the 12-hour shift as an acute care nursing job demand and as such, supports the identification of job resources to help alleviate stressors related to demands. The purpose of this study is to investigate approaches of support targeted to mitigate the adverse effects of working 12-hour shifts for nurses in acute care settings.
A modified, e-Delphi format was selected to engage a range of expert opinions. Three rounds of surveys will be administered to expert nurse leader participants who respond to AONL e-newsletter announcements. The first round will gather qualitative information about support and resources to mitigate the adverse effects of the 12-hour shifts, and the two subsequent rounds will synthesize round one data with a consensus identification and priority ranking of resources and recommendations for implementation of these approaches.
This initiative aligns with two of AONL’s Strategic Priorities. First, it focuses on supporting the Institute for Healthcare Improvement’s Quadruple Aim to improve the experience of the caregiver and improve patient safety. Second, it supports the development of evidence to help nurse leaders build and sustain a resilient workforce.
Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE, and Research Team
University of Colorado
$9,575 Sustainable Nursing Workforce Development Grant made possible by a generous gift from the Versant Center for the Advancement of Nursing®.
Further Testing and Refinement of the Professional governance Scale
The overall purpose of this proposal is to further test and refine the Professional Governance Scale.
Creating a positive work environment that promotes safe, high quality care and optimal well-being for patients, families and health professionals is a priority area of attention for nurse leaders. Shared governance was introduced over 40 years ago as a framework for structural empowerment and has repeatedly been demonstrated to enhance nurse satisfaction and the quality of patient outcomes. Subsequently, the practice setting has increased in sophistication and complexity.
Existing measures of shared governance concentrate on the existence of structures that enable structural empowerment, but not on the behaviors that provide evidence that registered nurses perceives they function as professionals who govern their work. While reviewing the literature to prepare a new instrument, a concept analysis demonstrated that the concept of shared governance has evolved to professional governance, and further described four distinct attributes and characteristics of professional governance: accountability, professional obligation, collateral relationships, and decision making1.
Within this framework, existing literature was used to develop a new instrument, the Professional Governance Scale (PGS), that consisted of 100 items representing behavioral demonstrations of the four attributes and their characteristics. Initial content validity testing reduced the instrument to 75 items2. Subsequent testing with data from five hospitals further reduced the instrument to 43 items. Exploratory factor analysis confirmed structural validity of the PGS subscales with strong item factor loadings and explained variance of 55% or greater.
The strong initial findings of the PGS demonstrate that this could be a valuable tool for nurse leaders and researchers to measure and to create practice environments that support professional nursing practice and quality patient outcomes. Funding would enable more rapid psychometric testing. This proposal is to secure funding to further refine the PGS by conducting overall structural and construct validity psychometric and model testing at both the individual and group levels in hospitals within three health systems.
Kelley Kostich, RN, PhD candidate
University of Missouri, Kansas City
$12,655 to investigate the nurse leader’s role in patient experience, safety and clinician well-being made possible by a generous gift from Careismatic Brands (formerly Strategic Partners, Inc.)
The Relationship Between Staff Nurses’ Perceptions of Nurse Manager Caring Behaviors and Patient Satisfaction
Purpose: The purpose of the study is to examine the relationship between nurses’ perceptions of nurse manager caring behaviors and patient experience. Significance: Patient experience is a reimbursable patient outcome providing financial motivation for healthcare organizations to make this metric a priority. Each year since 2015, patient experience scores from the Hospital Consumer Assessment of Healthcare Providers and Systems have remained flat. Additional research is needed to improve this outcome. Nurse job-satisfaction was found to be positively correlated to the nursing professional work environment, which impacts the patient experience. Nurses reported a higher job satisfaction when they perceived their managers as demonstrating caring behaviors. There is a gap in the literature regarding the caring element of nurse manager behaviors and the correlation to reimbursable patient outcomes, specifically patient experience. Effective nursing leadership is essential to fulfill the Institute of Medicine’s vision of nurses being full partners with other healthcare professionals as a strategy to transform healthcare. Further nursing research is needed on the impact the nurse manager caring behaviors have on patient outcomes such as the patient experience. Methods: Guided by the Quality-Caring Model, the relationship between staff nurses’ perceptions of nurse manager caring behaviors and the patient experience will be examined using a cross-sectional correlational design. The study will be conducted at an urban academic medical center located in the St. Louis metropolitan area. The Caring Assessment Tool-Administration (CAT-adm©) measures nurse manager caring behaviors from the perspective of the staff nurses. A convenience sample of inpatient staff nurses will be surveyed. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will measure patient experience. There are 36 inpatient departments eligible to collect nursing surveys and HCAHPS surveys. The data will be managed through Statistical Package for the Social Sciences (SPSS) program by the principal investigator. The principal investigator will complete the analysis with a faculty statistician. Demographic data for participants will be reported using descriptive statistics. Nursing Implications: This study will contribute to the discipline of nursing by providing new knowledge on how nurse manager caring behaviors impact patient experience. The new knowledge will contribute to nurse manager development programs regarding caring behaviors.
Association of Leadership Science in Nursing and AONL Foundation
Esther Chipps, PhD, RN, NEA-BC (Principal Investigator)
The Ohio State University Wexner Medical Center, The Ohio State University College of Nursing
Board Member, ALSN
M. Lindell Joseph, PhD, RN, FAAN (Co-Principal Investigator)
University of Iowa, College of Nursing
Board Member, AONL Foundation
Setting the Research Agenda for Nursing Administration and Leadership Science: A Delphi Study
A priority for ALSN is to advance research in nursing administration and leadership. Nearly five years ago, the ALSN identified nursing administration research priority categories and significant research emerged in those eight categories: economic value of nursing, design of future nursing practice and care delivery systems, healthy practice environments patient safety and outcomes research, leadership education, effective leadership using information technology to transform care, and innovative research design and frameworks.1 In assessing the progress since the publication of the Future of Nursing report, the National Academy of Medicine recognized the continued need to develop nurse leaders and collect workforce data to support research on new models of health care delivery that improve patient outcomes.2 To advance research in nursing leadership and administration, it is time to review and identify new nursing leadership/administration research priorities in order to establish the research agenda for 2020 and beyond. We propose that this research agenda will service to identify current gaps in our knowledge and provide a research trajectory for the next 5 years.
The aims of the study are:
- To identify nursing leadership and administration research topics of importance in the USA and Canada.
- To prioritize and reach consensus on the identified research priorities; and
- To develop a nursing administration research agenda for 2020-2025.
Cheryl Jones, PhD, RN and Donna Havens, PhD, RN
AONL Foundation CNO Turnover Study
Made possible by a generous gift from AMN Healthcare.
Chief Nursing Officers (CNOs) provide leadership that is critical to patient welfare, quality nursing practice and organizational performance. Typically leading the largest group of health professionals in a healthcare organization, CNOs "... bear much of the responsibility for ensuring a positive patient experience and for keeping tabs on quality and patient safety issues" (Hendren, 2011, p. 1). In hospitals, the CNO is responsible for developing and maintaining the capacity for care delivery, interpreting and advocating for nurses and patients, and influencing clinical, fiscal and administrative outcomes (American Organization for Nurse Executives [AONE], 2005; Caroselli, 2010; Havens, Thompson, & Jones, 2008; Jones, Havens, & Thompson, 2008; Jones, Havens, & Thompson, 2009; Kippenbrock, 1995; VHA, 2005). CNOs have long been responsible for maintaining and ensuring an adequate nurse workforce to meet patient care needs, maximize “quality of patient care, the professional satisfaction of nurses, and the goals of cost-effectiveness for the institution” (Clifford, 1998, p.5), but contemporary CNOs are responsible for demonstrating care value within and across organizational boundaries, and providing leadership during uncertain environmental changes.
Unfortunately, data on CNO retention, turnover and stability are limited (Bacheller, 2010). The American Organization for Nursing Leadership (AONL) and the AONL Foundation launched an important first step in 2006 by examining CNO turnover and retention on a national level. In collaboration with researchers at the University of North Carolina at Chapel Hill (Havens and Jones), AONL conducted a multi-phased study. Phase I gathered data via an online survey of current, interim and past CNOs to describe the CNO role, experiences with voluntary and involuntary turnover, and related CNO retention issues. Phase II used confidential telephone interviews with the same CNO population to gain additional insights into CNO turnover that augmented the online survey findings. Phase III surveyed staff nurses, nurse managers and directors to examine the impact of CNO turnover on care delivery. The team disseminated findings through multiple presentations and publications to raise awareness of this crucial role, the potential pending crisis and to raise awareness regarding needed strategies to ameliorate the situation.
This is the third study in a series of work to identify and monitor the status of U.S. CNO turnover and retention, taking advantage of the opportunity to compare CNO turnover at three points in time and develop a tested method for tracking CNO turnover into the future.